Why Psychiatry Needs to Scrap the DSM System: An Immodest Proposal

“It is much more important to know what sort of a patient has a disease than what sort of a disease a patient has.”~ Sir William Osler (Canadian Physician, 1849-1919)

Most psychiatrists, and many patients, sense that psychiatry is in trouble these days. The reasons are complex, but boil down to a crisis of confidence: many in the general public — if they ever had faith in psychiatry — have begun to lose it.

Many psychiatrists who, like me, began their careers with hopeful idealism are now expressing pessimism or cynicism. Here, too, the reasons are complex, and have much to do with the sense that psychiatry has drifted away from its core values and central mission: the relief of human suffering and incapacity. Of course, the corrosive influence of “Big Pharma” and the gradual decline in the use of psychotherapy have contributed to this down-beat attitude.

And the highly-publicized dust-up over revision of psychiatry’s diagnostic classification — the DSM-5 (what the media love to call, “Psychiatry’s Bible”) — has certainly not filled psychiatrists with joy.

A number of prominent psychiatrists have criticized both the process and content of the still-developing DSM-5. Some have alleged that the DSM work groups have been too insulated from outside review, and that their proposed revisions will lead to an unwarranted “medicalization” of life’s normal stresses and strains. For example, critics worry that conditions like ADHD or major depressive disorder will be “over-diagnosed” using the proposed new criteria, and that this will lead, in turn, to excessive use of psychotropic medication. There are arguments to be made on both sides of these issues — but in my view, the critics are merely nibbling around the edges of the real problem.

In truth, the entire premise underlying the DSMs is severely flawed—and many psychiatrists routinely ignore the DSM in their clinical practices. Indeed, if the DSM is psychiatry’s “Bible,” it is fair to say that a great many psychiatrists are heretics. In my view, psychiatry needs to scrap the present diagnostic system and begin afresh, with its core ethical and clinical mission firmly in mind. This means getting rid of the “One from column A, one from column B”, research-oriented, diagnostic criteria, and providing clinicians with a manual that is practical and useful.

The present model of psychiatric diagnosis is useful primarily for researchers. It suits their needs for uniformity in diagnosis, by providing a set of “necessary and sufficient” signs and symptoms that define a particular disorder. These cut-and-dried criteria help ensure what researchers call “inter-rater reliability.” But this well-intentioned attempt to “carve Nature at its joints” doesn’t capture the diverse ways psychiatric illnesses actually appear in clinical settings; nor does the DSM’s penchant for pigeon-holing comport with how most psychiatrists actually “diagnose” their patients.

Most experienced clinicians listen carefully to the patient’s personal and family history; weigh this narrative in light of some general diagnostic categories, and arrive a “gestalt” understanding of their patient’s condition. Sure, psychiatrists — like other mental health professionals — are required to “play ball” with third-party payers, and provide the official DSM code for a given patient’s disorder. But this doesn’t mean that psychiatrists place much stock in the DSM’s categorical approach to understanding so-called “mental disorders”. This term is itself highly problematic, as it perpetuates the Cartesian “mind-body” split. Indeed, the original DSM-IV (1994) acknowledged this problem. No term is perfect, but I’d rather see a “Manual of Neurobehavioral Disease” — or simply, “Manual of Psychiatric Disorders”–than one of “mental disorders.”

Titles aside, here is the core problem: the DSM framework does very little to enlighten the clinician regarding the “inner world” of the suffering patient.

Let me be clear: I have great respect for my friends and colleagues who have spent many years developing the DSMs. And, I do not mean to disparage the assiduous efforts of the DSM-5 workgroups to refine the present set of diagnostic criteria. Clinical research is crucial for psychiatry, and there is a need for very specific diagnostic criteria in order to assure that subjects in a research study actually warrant a particular diagnosis.

Indeed, I believe the present (DSM-IV) criteria could serve as a launching point for a more refined set, based on the latest scientific studies, which could then be used by psychiatric researchers. Whether to publish these research-oriented criteria as a separate manual, or to include them in an appendix to the main document, is not critical. The real issue is that, from the work-a-day clinician’s standpoint, the DSMs that have appeared in the last thirty years (DSM-III and IV) have managed to embody “the worst of both worlds”, despite the good intentions of their authors.

Why is this so? Well, on the one hand, none of the major DSM psychiatric disorders, such as schizophrenia and bipolar disorder, is linked to any specific biological abnormality or “biomarker” — the proverbial “lab test” so many in my profession have been seeking. This is nobody’s fault: it simply reflects our limited (though growing) biological knowledge in what is still a relatively young science.

On the other hand, the observation-based, symptomatic criteria of the DSMs shed little light on the inner workings of psychiatric illnesses — how the patient suffering from, say, schizophrenia actually experiences the world. It is one thing to list a few symptoms of schizophrenia, such as auditory hallucinations or paranoid delusions. It is quite another to understand the illness from the patient’s perspective — an approach known as phenomenology. I would argue that many recently-trained psychiatrists have had little exposure to the phenomenology of the major mental illnesses. Most have been steeped in the culture of symptom check lists — not in the sorrows of the soul.

The present DSM categories convey the impression that diseases have “necessary and sufficient” features that define them—akin to the Platonic concept of ideal “forms.” A contrasting view is that of the philosopher Ludwig Wittgenstein, who argued that such “essential” definitions do not represent how language actually works. Wittgenstein wrote, instead, of “family resemblances” that help characterize a particular word or category, in a particular context. By analogy, no single feature or features characterize all five members of, say, the Jones family; however, four of the Joneses have blond hair, three of those four have blue eyes, and four are very tall. We can see the “resemblances” when the Joneses stand together for the family photo. Wittgenstein compared family resemblances to the overlapping fibers of a rope—no single fiber is present throughout the rope, but a large number of fibers overlap so as to create a continuous and recognizable object. The same may be posited with respect to any given psychiatric disease category. There may be no single set of “necessary and sufficient conditions” that define schizophrenia or bipolar disorder; but patients who suffer with either illness resemble one another in very characteristic ways.

Almost contemporaneously with Wittgenstein, philosophers such as Edmund Husserl—and later, existentialists like Jean-Paul Sartre—began to emphasize the unique structure and contents of the individual’s experience: her way of “being in the world.” It is this phenomenological perspective that would inform what I call “disease prototypes” in psychiatry. Essentially, these are narrative accounts of illness that try to capture the most salient and typical features of the condition, emphasizing the typical patient’s subjective experiences. Such prototypes would compose the core of the diagnostic system I am proposing.

What might a narrative prototype of a psychiatric illness sound like? In the case of schizophrenia, perhaps something like this:

Sal is a 30-year-old single male whose chief complaint is, “I can’t find pieces of me, and the pieces I do have are fading, fading, fading, into inter-dimensional space.” Sal’s problems began when he was about 14. According to his parents, Sal began to withdraw from friends and schoolmates and “seemed to enter a world of his own.” He became increasingly unable to maintain his hygiene, school performance, or social relations, often spending days at a time secluded in his room and refusing to shower or speak. He would eat only foods that had been “de-contaminated from radiation”, which he believed was being “beamed” into the house. By age 18, Sal complained of “gamma rays eating away at my brain”, and described hearing several persons discussing him in derogatory terms while alone in his room. Sal sometimes feels that “my thoughts are leaking out of my head” and that others “can read my mind.” At times, Sal will laugh or giggle inappropriately, as when attending the funeral of a family member, and his family reports difficulty in understanding Sal when he does speak…

An actual disease prototype would be much more detailed, of course, and would incorporate most of the signs and symptoms now listed in the DSM criteria. For disease entities that have highly variable presentations, more than one prototype would be provided. Each prototype would be accompanied by the latest data on any known biological abnormalities associated with the particular condition; detailed demographic correlates; and common findings on the mental status exam. (Ideally, this would be followed by information on the best-validated treatment strategies for a given condition, but that might well require a separate treatment manual). Each prototype would be compatible with its corresponding “research diagnostic criteria” (RDC), but would be framed in very different terms. (The proposed DSM-5 criteria for schizophrenia may be viewed here).

In short, it is not enough for psychiatrists simply to peck away at the proposed DSM-5. True, we will be stuck with the DSM-5 for the next decade or two, and we should strive to improve it while we still can. But in the longer term, psychiatrists and other mental health professionals owe it to themselves and their patients to think more boldly — and more philosophically — about their diagnostic system.

Paris J: Commentary in : The Six Most Essential Questions In Psychiatric Diagnosis: A Pluralogue: Edited by James Phillips, M.D., & Allen Frances, M.D. Philosophy, Ethics, and Humanities in Medicine (PEHM) in press.

Pierre J: Commentary in The Six Most Essential Questions In Psychiatric Diagnosis: A Pluralogue: Edited by James Phillips,M.D., & Allen Frances, M.D. Philosophy, Ethics, and Humanities in Medicine (PEHM), in press.